| Code | Description | Claims | Beneficiaries | Total Paid |
|---|
| D1351 |
Sealant - per tooth |
15,985 |
2,359 |
$228K |
| D0150 |
Comprehensive oral evaluation - new or established patient |
5,718 |
4,135 |
$150K |
| D1120 |
Prophylaxis - child |
6,531 |
4,927 |
$121K |
| D1206 |
Topical application of fluoride varnish |
5,259 |
3,996 |
$77K |
| D0140 |
Limited oral evaluation - problem focused |
1,719 |
1,459 |
$56K |
| D0272 |
Bitewings - two radiographic images |
3,334 |
2,485 |
$44K |
| D0350 |
|
1,893 |
1,241 |
$29K |
| D1208 |
Topical application of fluoride, excluding varnish |
2,035 |
1,578 |
$22K |
| D0274 |
Bitewings - four radiographic images |
787 |
689 |
$19K |
| D2392 |
Resin-based composite - two surfaces, posterior, primary or permanent |
160 |
97 |
$18K |
| D0120 |
Periodic oral evaluation - established patient |
875 |
739 |
$18K |
| D0330 |
Panoramic radiographic image |
117 |
117 |
$7K |
| D9230 |
Inhalation of nitrous oxide / analgesia, anxiolysis |
137 |
133 |
$5K |
| D0220 |
Intraoral - periapical first radiographic image |
111 |
111 |
$2K |
| D0230 |
Intraoral - periapical each additional radiographic image |
58 |
55 |
$669.00 |
| D0145 |
Oral evaluation for a patient under three years of age |
12 |
12 |
$497.82 |
| D0603 |
|
691 |
655 |
$0.00 |